Breast Cancer in Men

Breast Cancer in Men

In this issue of ONCOLOGY, Dr.
Aman Buzdar provides a timely
synopsis of current perspectives
on breast cancer in men. I would only
add or expand upon a few points.
Because of its rarity, breast cancer
in men has largely taken a backseat to
the worldwide effort to control this
disease in women. Fortunately, the
spotlight on women has included similarly
affected men in its penumbra.
The result has been increased visibili-
ty for the problem in men. Biologically,
breast cancer is similar in both
sexes, and in comparable stages is no
less curable in men. The different features
seen in men can largely be attributed
to the less estrogenic milieu
in which the disease arises.
The small number of cases does
impose limitations. Clinical experience
is necessarily anecdotal or retrospective.
Knowledge based on
randomized clinical trials is nonexistent,
and women provide the model
for treatment. Screening with mammography,
which has contributed to
earlier diagnosis and a declining death
rate among women, is not feasible.
Nor is the application of breast
sparing technology. For the foreseeable
future, earlier diagnosis in men
is dependent on public education,
individual awareness, and alert
physicians.
Risk Factors in Men
The strongest risk factors for men
are age, a family history of breast
cancer, and a genetic predisposition. I
would add that ionizing radiation of
the chest wall and Ashkenazi Jewish
ancestry are also suspected of placing
men at increased risk.[1,2] To date,
no "Gail model" for calculating individual
risk in men is available. Dr.
Buzdar listed benign breast disease as
a risk factor (see Table 1 in his article),
but benign breast disease is exceedingly
infrequent in men.
Gynecomastia is common and increases
with age, but gynecomastia is
a symptom rather than a disease. It
increases the glandular substrate for
breast cancer and usually reflects an
estrogenic stimulus, but the relationship
of gynecomastia to breast cancer
is not clear. In the past, surgeons felt
obligated to biopsy every case of gynecomastia
to rule out cancer. But
unless the clinical examination, mammogram,
or ultrasound suggests
cancer, biopsy is not necessary. Symptomatic
gynecomastia should be investigated
to determine its cause.
Surgical Treatment
I would make two comments about
surgical treatment of men with early
stages of breast cancer. The first is
that there may be a small place for
breast-sparing therapy. Preservation
of the breasts of men ordinarily has
not been feasible, nor has it been a
high priority. Cancer almost always
occurs beneath the nipple, necessitating
its removal and eliminating the
cosmetic value of breast preservation.
Occasionally, however, investigation
of nipple discharge in a man leads
to the discovery of a small, low-grade
noninvasive ductal carcinoma in situ
(DCIS) that can be widely encompassed
surgically. In such cases, a subcutaneous
mastectomy may be, and
in the experience of the author has
been, sufficient to provide lasting freedom
from recurrence. For women,
Silverstein's carefully analyzed retrospective
data support wide local
excision alone for cases of small, lowgrade
DCIS.[3] Again by analogy,
lumpectomy and irradiation may be
an option for the occasional man who
presents with a small discrete inva
sive breast cancer located in a quadrant
wide of the nipple if the guidelines
used for treatment of women
can be fulfilled.
Sentinel Lymph Node Biopsy
My second comment regarding early
disease is that axillary sentinel
lymph node biopsy (SLNB) is now an
option for men with breast cancer. In
women with a clinically negative axilla,
SLNB has proven to be highly
reliable in identifying the pathologically
uninvolved axilla so that axillary
dissection and the resulting risk
of lymphedema can be avoided. Axillary
dissection in men results in a
similar frequency of lymphedema of
the arm. One (20%) of the last five
men I have treated with mastectomy
and axillary dissection developed burdensome
lymphedema. Although the
experience with SLNB in men with
breast cancer is scant, it is based on a
rationale similar to that in women,
employs a similar technique, and limited
information suggests it has a similar
efficacy.
Albo et al reported on five men with
breast cancer at M. D. Anderson Cancer
Center who underwent SLNB.[4]
One man had a positive sentinel node,
and axillary dissection revealed additional
positive nodes. Of the four men
with a negative SLNB, three had axillary
dissections, and no positive nodes
were found. In another review of 16
male breast cancer patients who underwent
axillary SLNBs at Memorial
Sloan-Kettering Cancer Center, a sentinel
node was identified in all but one
case, and no false-negative sentinel
nodes were reported. The investigators
concluded that the procedure is as successful
in men as it is in women, and
may be offered as an option to men with
early-stage breast cancer by surgeons
experienced with the technique.[5]
Postmastectomy chest wall irradiation
is appropriate for men at high
risk for local recurrence and generally
follows the indications established
for women, ie, a large or locally advanced
primary or multiple (four or
more) positive nodes. Following the
current policy for women, systemic
adjuvant chemotherapy would precede
radiation.
Metastatic Disease
Dr. Buzdar clearly presents the options
for treating metastatic disease. I
would add that in the new TNM staging
system, stage IV disease no longer
includes cases with isolated supraclavicular
metastases, a group (among
women) that has a better survival rate
than those with more distant metastases.
Whether the relatively favorable
prognosis is also true for men is uncertain,
but this possibility encourages
vigorous locoregional and systemic
therapy in these cases. When both hormonal
and chemotherapy are used,
chemotherapy ordinarily precedes
hormonal therapy.

Disclosures

The author(s) have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.